Certificate of registered medical practitioner
authorising cremation
Cemeteries and Crematoria Act 2003
Cemeteries and Crematoria Regulations 2015
Form 4 (Regulation 19, Schedule 1)
Note 1:
In accordance with section 138 of the Cemeteries and Crematoria Act 2003 this form must be completed by a
registered medical practitioner who is NOT the registered medical practitioner who completed the notice as required
under section 37(2) of the Births, Deaths and Marriages Registration Act 1996 in respect of the death of the deceased
person who is to be cremated.
Note 2:
This form is not required for the cremation of a still-born child. For all perinatal deaths, please check the ‘Medical
Certificate of Cause of Perinatal Death’ to confirm whether the application relates to a still-born child.
Please complete in block letters
The deceased
Full name:
Sex:
Male
Female
Date of birth:
/
/
Date of death:
/
/
Place of death:
Certificate
I, [name of registered medical practitioner]
of [address of registered medical practitioner]
certify that:
1. I am a currently registered medical practitioner under the Health Practitioner Regulation National Law.
2. I have carefully read the statements contained in the ‘Application for cremation authorisation’ relating to
the deceased,
signed by [applicant for cremation authorisation]
and dated [date of application for cremation authorisation]
/
/
3. I have examined the body of the deceased.
4. I have sighted:
a completed ‘Medical Certificate of Cause of Death’ of a person aged 28 days or over prepared pursuant to
section 37(2) of the Births, Deaths and Marriages Registration Act 1996; or
a completed ‘Medical Certificate of Cause of Perinatal Death’ prepared pursuant to section 37(2) of the
Births, Deaths and Marriages Registration Act 1996.
AND I state that:
1. I have made careful and independent inquiry into the circumstances surrounding the death of the deceased.
2. I agree with the cause of death as shown on the notice given under section 37(2) of the Births, Deaths and
Marriages Registration Act 1996.
3. In my opinion the death is not reportable or reviewable under the Coroners Act 2008.
4. In my opinion, there is no circumstance concerning the death of the deceased that might necessitate further
examination of the body before it is cremated, or which could, in my opinion, make exhumation of the body
necessary at any time in the future.
5. In my opinion there is no reason why the cremation should not proceed.
6. Apart from any fee payable for the provision of this certificate, I have not acquired and do not anticipate
acquiring directly or indirectly any property or pecuniary or other benefit of any description by reason of the
death of the deceased.
7. I am not in partnership with, nor will I derive any professional remuneration from, any registered medical
practitioner who professionally attended the deceased.
Indicate which of the statements below applies by ticking the box next to the statement (if a registered medical practitioner
refuses to sign a ‘Certificate of registered medical practitioner authorising cremation’, he or she must clearly endorse that fact
on this certificate).
I authorise the cremation of the deceased.
I refuse to authorise the cremation of the deceased on the grounds that:
Title:
Given names:
Surname:
Address:
Suburb/town:
Telephone
State:
Home:
Work:
Post code:
Mobile:
Email:
Medical practitioner registration number:
Signature:
Date:
/
/
Warning
Under section 140 of the Cemeteries and Crematoria Act 2003 it is an offence to make a false statement in a
‘Certificate of a registered medical practitioner authorising cremation’, punishable by a fine of up to 600 penalty
units or 5 years imprisonment or both.
Privacy statement
Any personal information provided in this certificate will be treated in accordance with the principles set out in the
Privacy and Data Protection Act 2014. Any health information provided in this certificate will be treated in
accordance with the principles set out in the Health Records Act 2001. An individual may request access to the
information we hold about them in relation to the certificate and the associated application, and may request its
correction if necessary.
The information provided is required to enable the certificate to be processed and to inform an individual of
matters concerning the certificate and the associated application. The information may also be needed to perform
functions, comply with obligations and exercise rights under the Cemeteries and Crematoria Act 2003. Except for
the information you are required to submit under that legislation, you are not obliged to provide any personal
information. However, should you choose not to provide personal information, the certificate and the associated
application may not be able to be processed and services may not be able to be provided.
Certificate of registered medical practitioner authorising cremation
2